The Challenge of Dual Diagnosis.

Researchers have made great strides in understanding and treating alcoholics with co-occurring psychiatric disorders. Improved diagnostic criteria are available, and research has demonstrated that both disorders must be addressed if the dually diagnosed patient is to have the best chance for a good outcome. The best type of treatment program is an integrated approach, assuring that treatments will be coordinated for best effect. Additional research is needed to match optimum treatment approaches with cost-effective reimbursement practices.

T he traditional view that psychi 1995) and have higher rates of home than 20,000 residents of households, atric disorders are unrelated to lessness and legal and medical problems group homes, and longterm institu alcohol and other drug (AOD) as well as more frequent and longer tions in five sites across the United use problems 1 has hampered effective hospitalizations (see Center for Sub States (Regier et al. 1990). The ECA treatment of patients who exhibit both stance Abuse Treatment [CSAT] 1994). found that 13.5 percent of respondents types of disorder (Ries 1993;Miller Patients with dual disorders may be had experienced an alcoholuse disorder 1994). Psychiatric and AOD disorders misdiagnosed and improperly treated, at some time in their lives, 6.1 percent produce many similar symptoms and often "falling through the cracks" in had experienced other druguse disor often coexist in the same patient, where the health care system (Merikangas and ders,and 22.5 percent had experienced one disorder can influence the course Gelernter 1990; Minkoff 1989; Ries nonAOD psychiatric disorders (Regier and treatment outcome of the other. 1993). For example, alcoholics with et al. 1990). Lifetime prevalence for The existence of two or more different psychiatric disorders may be rejected by any psychiatric or AOD disorder was disorders in the same patient is referred both alcoholism programs and mental 34 percent (Helzer and Pryzbeck 1988). to as comorbidity. Patients with co health programs (National Institute on Overall, the lifetime prevalence for any morbid AOD and psychiatric disorders Alcohol Abuse and Alcoholism 1991 orders and their treatment from more cal Center. structured psychiatric interviews to more than 8,000 respondents ages 15 to 54 in the noninstitutionalized civilian population of the United States. The NCS found higher rates than the ECA for any or all lifetime disorders (i.e., 48 percent) (Kessler et al. 1996). As in the ECA, the NCS found most mental disorders to be more common among persons with a current or lifetime AOD diagnosis than among those who had never experienced AOD problems (Kessler et al. 1996). The NCS also found that most dis orders had their onset prior to the on set of the AOD disorder. A significant exception to this general finding was mood disorders (e.g., depression) among male alcoholics, which usually developed after the onset of the alco holism (Kessler et al. 1996).

PSYCHIATRIC PROBLEMS ASSOCIATED WITH AOD DISORDERS
Dually diagnosed patients most often exhibit symptoms of an apparent mood disorder that can range from dysthymia to a major depressive episode. Symp toms of anxiety are also a common feature, often mixed with symptoms of depression. Disorders that involve disturbances in thinking, such as mania and schizophrenia, occur less frequently.
As discussed below, the occurrence of isolated psychiatric symptoms, how ever severe, does not always justify the diagnosis of an independent psy chiatric disorder. Nevertheless, ECA data indicate that alcoholics are also 21.0 times more likely to have a diag nosis of antisocial personality disorder compared with nonalcoholics. 3 Simi lar statistics (i.e., odds ratios) include 3.9 times for drug abuse; 6.2 times for mania; and 4.0 times for schizophrenia. Despite the association of symptoms of depression and anxiety with alcoholism, this survey found only a mild increase 3 The relationships between antisocial personal ity disorder and alcohol are extremely complex and therefore cannot be fully discussed here. For further discussion, see Hesselbrock and col leagues (1986). in major depressive disorder and es sentially no increase in anxiety disorders in alcoholics compared with nonalco holics (Helzer and Pryzbeck 1988).

WHAT ACCOUNTS FOR DUAL DIAGNOSIS?
The extensive association between alco holism and psychiatric disorders does not directly support any conclusions about causality. Any of various factors might contribute to dual diagnosis, in cluding the following (Schuckit 1986;Meyer 1989): (1) alcoholism and a psy chiatric disorder can cooccur, either sequentially or simultaneously, by coin cidence; (2) alcoholism can cause certain psychiatric conditions or increase their severity; (3) psychiatric disorders might cause alcoholism or increase its severity; (4) both alcoholism and a psychiatric disorder may be caused separately by some third condition; (5) alcohol use or alcohol withdrawal can produce symp toms that mimic those of an indepen dent psychiatric disorder.
The development of these concepts has advanced our understanding of dual diagnosis. Earlier schools of thought about possible causal relations of psychiatric and AOD disorders ap proached opposite ends of a continuum based on the differing perspectives of addiction and psychiatric professionals (Schuckit 1985).
Many alcoholism researchers and clinicians have expressed the view that all or most comorbid psychiatric prob lems are produced by alcohol use and are therefore secondary to the alcohol ism. In this view, adequate treatment of alcoholism is sufficient to resolve cooccurring psychiatric problems, and additional psychiatric treatment is usu ally unnecessary. At its extreme, this view has resulted in alcoholics being advised at selfhelp group meetings to discontinue essential psychiatric medi cations (Woody et al. 1995).
At the other end of the continuum is the view that alcoholism may develop when people take drugs to selfmedicate symptoms of a preexisting psychiatric disorder. This hypothesis implies that treatment of the psychiatric problem is The Challenge of Dual Diagnosis necessary and even sufficient for treat ment of the alcoholism. In extreme cases, clinicians have treated some dually diagnosed patients psychiatri cally for years without making any effort to address the patients' alco holism directly (Woody et al. 1995;Miller 1994).

Toward an Integrated View
Most current data indicate that each of the above views may be true, to a greater or lesser extent, in different patients. Extensive research indicates that alcohol use can produce psychi atric symptoms or exacerbate existing ones (McLellan et al. 1979;Schuckit 1983;Schuckit and Monteiro 1988). This finding is especially clear in the case of depression and anxiety produced by alcohol consumption or withdrawal. 4 Alcoholinduced psychiatric symptoms decrease with abstinence, providing evidence that they are not independent disorders (Kadden et al. 1995).
In addition, alcoholics undergoing prolonged periods of alternating in toxication and withdrawal often ex hibit symptoms such as hallucinations and thought disturbances. Although these symptoms suggest schizophrenia or mania, they can be induced by alco hol consumption in the absence of an independent psychiatric disorder (Miller 1994).
With respect to selfmedication, many case reports and much clinical experience indicate that some patients use alcohol to reduce the intensity of the anxiety, tension, depressed mood, insomnia, apathy, and social isolation associated with independent mental dis orders (Khantzian 1985;Goodwin and Jamison 1990). Perhaps because of impaired perception or lack of insight, mentally disordered persons may persist in such use despite longterm alcohol induced worsening of their symptoms (Winokur et al. 1995). Whether use of alcohol for selfmedication can devel op into true alcoholism in susceptible 4 Withdrawal is a syndrome that begins 6 to 48 hours after cessation of alcohol consumption. It is characterized by tremors, elevated blood pressure, hallucinations, and, in severe cases, seizures.
people is a matter of debate (Raskin and Miller 1993;Winokur et al. 1995). 5 The existence of multiple paths to the development of psychiatric symptoms highlights the importance of patient diversity (i.e., heterogeneity) and the need for individualized assessments (Rounsaville et al. 1983). Epidemio logic studies group subjects according to their similarities and help minimize the effects of rationalization and denial (Hesselbrock et al. 1986). However, awareness of the multiplicity of ge netic, psychosocial, and other factors is important to the diagnosis and treat ment of the individual patient (Roy et al. 1991).

DIAGNOSIS
Current advances in diagnosis include the use of structured interviews, specific descriptions of alcoholinduced mental disorders, and guidelines for differen tiating alcoholinduced from primary mental disorders (i.e., the Diagnostic and Statistic Manual of Mental Disor ders, Fourth Edition [DSM-IV]). These advances are contributing to the devel opment of more complex models and a better understanding of these disorders.
Effective treatment of dual disorders begins with a thorough diagnostic as sessment. The frequent occurrence of psychiatric or addictive symptoms in the absence of an independent disorder, as discussed previously, suggests the importance of distinguishing between drinking and alcoholism; sadness and depression; and anxiety feelings and major anxiety disorders (Schuckit and Monteiro 1988 (SCID); the Composite International Diagnostic Interview (CIDI); and the Diagnostic Interview Schedule (DIS) (for review, see Grant and Towle 1990 and Allen and Columbus 1995). Efforts are under way to modify these instru ments according to DSM-IV guidelines.

DSM-IV Guidelines
The DSM-IV (American Psychiatric Association [APA] 1994) is a standard guide to defining and diagnosing psy chiatric and addictive disorders. In many cases, the DSM-IV provides ex clusionary criteria to help distinguish between AODinduced symptoms and independent disorders.
According to the DSM-IV guide lines, psychopathology should be labeled AODinduced if (1) it occurs only during periods of intoxication or withdrawal, (2) the symptoms are consistent with those of the particular AOD's that the patient is using, and (3)

TREATMENT
Because each dual disorder can aggra vate the course of the other, both dis orders must be treated if the patient is to have the best chance for a good out come (Woody et al. 1995). The first step in treatment is to perform an ac curate diagnosis. The treatments recom mended are similar to the treatments effective for the individual disorders (Woody et al. 1995). For example, a patient with alcoholism and mania needs alcoholism treatment that may involve detoxification followed by alcoholfocused therapy and participa tion in a selfhelp group. In addition, the patient must simultaneously re ceive ongoing psychiatric treatment with appropriate antimanic medication (e.g., lithium). All these treatments can be provided by a single clinician trained in both ap proaches or by a team of specialists. For example, alcoholism therapy is admin istered individually or in a group setting by one or more alcoholism counselors, whereas the psychiatric treatment (in cluding counseling and medications management) is administered by a psy chiatrist. The main requirement for a successful outcome is that the treat ments be coordinated. In addition, the treatments are usually most effective when delivered in the same setting, because that arrangement fosters good communication between members of the treatment team and is most conve nient for the patient.
Unfortunately, this kind of coordi nated care is often unavailable. Arbi trary and historically based separations exist between the mental health and alcoholism treatment systems. Tradi tionally, each system treats only one kind of disorder; consequently, the pa tient must enroll in separate programs to achieve total care (Green 1996). This poses special problems for the dually diagnosed, who tend to have difficulty organizing their affairs and who may lack the means of transportation be tween facilities.
Special dual diagnosis programs have been developed to address this problem. Many of these programs have been established within inpatient psy chiatric units, resulting in high costs that may not be authorized by managedcare organizations. Outpatient programs are less expensive and can be highly ef The Challenge of Dual Diagnosis fective if they are appropriately staffed and backed up by inpatient services for emergencies.
Currently, even outpatient programs have become subject to cost cutting, often constraining providers to focus on treating only one of the two dual disorders (Kessler 1996). This practice undermines the concept of integrated treatment and may eventually result in even higher costs through the increased need for expensive followup emergency and inpatient services.

Delivery of Treatment
Three general approaches are used in delivering treatment to the dually diag nosed patient. One approach is to treat one disorder first and then the other (i.e., sequential treatment); the second approach is to treat both disorders si multaneously but in different settings (i.e., parallel treatment); the third is to treat both disorders simultaneously in the same setting (i.e., integrated treat ment). Historically the most common approach to dual diagnosis has been sequential treatment. Some clinicians believe that addiction treatment must be administered first, so that the pa tient can be in stable recovery before entering psychiatric treatment. Other clinicians believe that psychiatric treat ment should be administered first. Still other clinicians believe that the relative severity of the patient's addictive or psychiatric symptoms should determine sequence of treatment or that the dis order that appeared first should be treated first (Miller 1994).
In practice, treatment sequence should vary depending on the situation. For example, psychiatric problems re quire immediate attention among pa tients exhibiting acute episodes of a major psychiatric disorder, whether alcoholrelated or independent. Exam ples include schizophrenia, mania, AODinduced psychoses, or AOD induced depression with suicidal be havior. In other cases, the AOD disorder tends to be treated first (Woody et al. 1995).
In the parallel approach (Miller 1994), treatment for both disorders is administered simultaneously, although generally at different facilities. For example, a patient may participate in AOD education and drug refusal classes at an addiction center; participate in a selfhelp group, such as Alcoholics Anonymous; and attend group therapy and medication education classes at a mental health center. Both parallel and sequential treatment utilize existing treatment programs and settings. Thus, mental health treatment is provided by mental health clinicians, and addiction treatment is provided by addiction treat ment clinicians. Coordination between settings is variable, and patients may re ceive conflicting explanations and ad vice. Sequential and parallel treatment may be most appropriate for patients who have a very severe problem with one disorder but a mild problem with the other (CSAT 1994).
A third model, called integrated treatment, combines elements of psy chiatric and AOD treatment into one single program. Because a sufficient number of staff members are trained in both treatment approaches, diagnosis and treatment for both disorders can be conducted simultaneously, minimizing conflicts between the two approaches (Minkoff 1989). The integrated model is particularly suitable for comorbid pa tients who require relatively intensive or continuous psychiatric care. A limi tation of the model is the tendency to undertreat addictive disorders and over treat psychiatric disorders in patients seeking treatment for the psychiatric consequences of AOD disease (Mink off 1989;Ries 1993).
The few studies that have assessed the outcome of integrated treatment have demonstrated effectiveness (Hoff man et al. 1993;Drake et al. 1993). One strength of this approach is its conve nience to patients, thereby ensuring bet ter compliance. In addition, integrated treatment enables most dual diagnosis patients to be "mainstreamed" into the basic addiction program, may reduce the patients' sense of isolation, and may cost less than having patients treated in more than one location. In such inte grated programs, many dual diagnosis patients can attend the same group or individual therapies as other patients and can participate in alcoholism treat ments based on medications that help prevent relapse (e.g., naltrexone). In addition, certain antidepressants (e.g., desipramine) may decrease alcohol consumption among depressed alco holics whose depression improves in response to medication (Mason 1996).

CONCLUSIONS
Researchers have made great strides in understanding and treating persons with dual diagnoses. Improved diag nostic criteria are available and re search has demonstrated that dually diagnosed patients have the best treat ment outcomes only when both prob lems are addressed. The best type of treatment program is an integrated ap proach; although the treatments used are generally the same ones that are used for each disorder when treated separately, integration ensures that treatments will be coordinated for best effect.
One problem of dual diagnosis that is common to all current medical treat ment is the lag between research ad vances and the practices of health maintenance organizations and other providers. Too often, singledisease management programs (i.e., "carve outs") dissociate addictionfocused treatment from medical, psychiatric, and other interventions that are needed by the patient, undermining the ability to develop integrated treatment models. Available data indicate that this disso ciation is unwise, as discussed recently by Kessler and colleagues (1996). The development of costeffective reim bursement practices must keep pace with developments in the effective treat ment of people with dual disorders. ■ REFERENCES ALLEN, J.P., AND